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Emergency Shelter AGREEMENT
Note: This form should only be completed by mothers who have been referred and approved by a partner organization.
*
Indicates required field
Mother's Name
*
First
Last
Phone Number
*
Email
*
Previous Address
*
Line 1
Line 2
City
State
Zip Code
Country
Names & Ages of Children
*
What circumstances have caused you to need emergency shelter?
*
Shelter From the Rain Emergency Shelter Requirements
I agree that the following are true:
1. I am a single mother/parent and I am not legally married.
2. I am currently homeless and have no other options for shelter.
3. I am pregnant or in custody of at least one of my children.
I agree that I meet all the requirements listed above:
*
Yes
No
Shelter From the Rain Emergency Shelter Terms & Guidelines
I agree to the following during my stay:
1. I understand that only myself and my children are permitted to stay in the room provided by Shelter From the Rain. If I violate this term, my stay can be terminated immediately.
2. I understand that I am not permitted to charge any other items to the room during my stay.
3. I understand that I am responsible for any damage done to the room during my stay.
4. I understand that I must check out of the hotel on the agreed date set by the hotel.
5. I understand that Shelter From the Rain is not responsible for any items lost, left or stolen during my time at the hotel.
6. I understand that I need to contact Shelter From the Rain at 912-232-5860 if I need to leave the hotel earlier than expected.
7. I understand that this is temporary shelter with a limited number of nights for shelter and I will work on a long-term solution while I am here.
Do you agree to the terms and guidelines of Shelter From the Rain's Emergency Shelter listed above:
*
Yes
No
Confirmation Check Box - Please Note: If any of the above information is not accurate, emergency shelter can be terminated.
*
By checking this box, you confirm that the information provided above is accurate.
Submit